EUTHANASIA Will assisted dying apply to 'just a few'?

by Craig Wallace

News Weekly, October 25, 2014

Ian Maddocks, emeritus professor of palliative care at Flinders University and Senior Australian of the Year 2013, wrote a reflective piece in the Melbourne Age (August 7, 2014), in response to a decision of the Medical Board of Australia to use emergency powers to immediately suspend the then Dr Philip Nitschke, after he admitted to supporting 45-year-old Perth man Nigel Brayley in his decision to commit suicide, despite knowing he was not terminally ill.

Euthanasia campaigner

Philip Nitschke promoting

life-ending drugs

Professor Maddocks’s intelligent piece crystallises a dilemma faced by euthanasia advocates in the wake of the Nitschke deregistration. They are now attempting to craft a new argument for medically-assisted dying based on process, nuance and evidence, not just on appeals to emotion or the idea of suicide as the exercise of a personal right.

There are lessons here too for the anti-euthanasia lobby, which has sometimes similarly allowed itself to be painted into a corner with black and white arguments founded in dogma.

As Professor Maddocks’s piece highlights, the reality of patients’ lives and doctor’s interventions is nuanced and dogma-defying. There are shades of grey, changes in circumstances and many forces which might weigh on decisions.

For medically-assisted dying to become ethical, a doctor would need to be sure of all the factors weighing in a person’s mind, not just at a point in time, but across time. People change their minds. They have good days and bad days.

A doctor would also need to be alert to a layer of emotional, financial and family pressures which might be brought to bear on those considering ending their lives. It is not hard to imagine what these pressures could be in a family experiencing financial hardship.

Given the difficulty for a busy doctor to obtain such a spread and depth of insight, it is little wonder that Professor Maddocks concludes that a desirable result would be one in which medically-assisted dying was available to “just a few”, and for most as an option for peace of mind, but rarely used.

It is here that problems begin anew. In an ideal world of total empathy, where we understood what each of us meant all of the time, I might support voluntary suicide in extremis on medical grounds for these few.

But we don’t live in a world of crystal clarity, so the issue becomes how definitions in legislation, conceived by mortals, will be interpreted by other mortals.

Legislators and doctors alike are mortal. Ask the NSW Independent Commission Against Corruption or the Australian Medical Board, the latter of which has now been forced to strike off one of its own. Definitions such as “voluntary” or “unbearable” sound like definitive terms, but they are open to widely differing interpretations and steeped in uncertainty.

Let’s start with “unbearable”. Most lives involve periods of discomfort and pain — physical, emotional, mental — suffered by us or by others. Unrequited love can be one kind of incurable pain; depression or arthritis can be another. Each of these may seem unbearable at a particular time.

I know people with disabilities who have gone through grief and loss, including suicidal feelings, and emerged with a love of life equal to anyone else’s. Everyone can change choices over a lifetime — or reach an acceptance of one’s life as it is. But there is no “undo” button for death.

It’s because concepts in the euthanasia debate can be so fluid and personal that the envisaged candidates for euthanasia seem to shift from people in pain because of cancer to people in pain because of quadriplegia or even people suffering chronic depression.

Let’s talk about “voluntary”. All of us know volunteering is not always practised consistently in families, even at the best of times. A request, such as “Would you like to take the garbage out this week?”, may get a different response depending on the tone of voice used when the request is made.

Think how much more difficult it would be to prove that euthanasia was genuinely voluntary in the case of a patient undergoing complicated medical treatment for a long illness, the expense of which is devouring the wealth that his family hopes to inherit.

In this example, the patient’s decision would not necessarily be based solely on whether he was suffering unbearable pain, but could be influenced by an unspoken expectation that he should “do the decent thing” and terminate his life sooner rather than later.

In this way, euthanasia, once legalised, would not be restricted to “just a few”, but could end up being applied to “the many”.

Words aside, we have not done all that we practically can for the few either. If we are envisaging medically-assisted dying as a last resort, should we not first deploy all the options which might reduce symptoms such as nausea and pain?

Evidence-based medical practices to relieve pain and distress should be the norm rather than looking to quick-fix legislative solutions to permit assisted dying. The latter solutions are often introduced into the public arena in the form of private members’ bills, which arise from the private member’s personal conviction rather than as a result of careful public consultation, including with people in the disability community.

The journey of euthanasia advocate Dr Philip Nitschke from medical practitioner to outcast, like America’s late Dr Jack Kevorkian before him, is a cautionary tale of the dangers of letting hearts rule minds in this complex issue.

Time and again, we see how countries which have legalised euthanasia seldom restrict it to “just a few” well-defined people.